SCHOOL OF MEDICINE
MATERIAL TRANSFER APPROVAL SHEET
OUTGOING
PROVIDING SCIENTIST:
DEPARTMENT:
EXT:
EMAIL:
RECIPIENT SCIENTIST:
ADDRESS:
PHONE:
EMAIL:
MATERIAL REQUESTED:
PLEASE PROVIDE OR ATTACH A BRIEF DESCRIPTION OF RESEARCH USE:
MTA Questionnaire
1. Were the materials developed/isolated in your lab?
If not, where were they developed or obtained?
Yes
2. Were the materials originally obtained from or developed in research with an academic or corporate
entity?
If yes, please explain:
3 Are there any patent disclosures related to the materials? Licenses?
4. Are the materials subject to restrictions under an existing agreement with a third party, (e.g., cre-lox?)
If yes, please identify the agreement and institution/company involved:
5. Are you aware of other restrictions to be placed on use of the material aside from what is contained in
the MTA? Explain.
6. Are the materials described in a publication or are they under limited disclosure?
If published, please provide the citation:
7. Are the materials tissues or fluids obtained from a living human?
8. Are the materials accompanied by patient identifying information?
9. If required, does the recipient organization have IRB Approval?
10 Are there any restrictions on transferring the tissue or fluids to others?
11 Do you need to be reimbursed by recipient organization for the cost of making or shipping the
materials?
If yes, what are the associated costs?
Additional Comments:
P.I. Signature:
Date:
Director, SOM Office of Grants & Contracts Signature
Date:
No